have
become an integral part of our culture, having
both a positive and negative impact on our daily
lives. They’ve changed the speed of information
exchange, powerfully affecting our everyday
existence and touching nearly every feature and
department in this issue of Maryland Physician.
Social media affords you the opportunity to
connect with your patients for health and
wellness education, disease management and
healthcare delivery. Social media raises
awareness of risks for and treatments of disease. The news of Angelina Jolie’s
preventative double mastectomy (a treatment option in response to a rare genetic
mutation for breast cancer) was instantaneously communicated via social media. In our
cover story (page 10), we’ve consulted with Maryland experts on treating the three top
cancers, so that you’re better informed when your patients ask about aggressive
treatments such as the one elected by Ms. Jolie, or developments in radiation therapy
for lung cancer or screening for and treating prostate cancer.
Digital media delivers real-time data and information that has a positive impact on
care delivery and reporting, yielding quality data such as such as readmission rates or
ER returns. Maryland is ahead of many states in connecting electronic information from
one provider to another; while interoperability presents its challenges, the benefits are
clear – see Healthcare IT (page 26).
In Policy (page 14), we interviewed Rebecca Pearce, executive director of the
Maryland Health Benefit Exchange. Our conversation with Ms. Pearce spotlights the
Maryland Health Connection, the health insurance marketplace for Marylanders where
patients and small businesses can digitally compare insurance plans and costs. We
discuss the impact this marketplace may have on those of you running your own
practices, including the potential influx of patients – some of who may be new to the
concept of having a primary care physician.
Health insurance companies target patients that are less expensive to carry – the
young, healthy and those most savvy in managing their chronic diseases – to offset those
who are more expensive to insure. These younger and savvier patients are the same ones
who have immediate access to information on your reputation as a provider as well as
disease and treatment options. Research demonstrates that patients are more likely to
trust online information about you than information gathered anywhere else.
Do you know what your online reputation is, and how to manage it? In October,
Maryland Physician Events launch with “Reputation Management & Social Media
Evolution for Medical Practices: Reactive, Proactive and Legal Implications.” Join us
to learn how you can best engage with your patients and manage your online reputation,
while understanding the legal implications. See page 6 for speakers, dates and locations.
Managing a practice may be more stressful than ever. Take a break from it; turn off your
smart phone, shut down your computer and head outside this fall. Living (page 30)
showcases one of the most beautiful spots on the East Coast found right here in Maryland –
Rock Hall. The word is that the waterfront beauty found there is like no other.
To life!

Director of Web & Communications Technology at the University of Maryland Medical System
and is responsible for all aspects
of their web programs. Mr.
Bennett led the UMMS online
initiatives designed to educate
and attract new patients. He’s
pioneered search engines optimization techniques that are now
standard for hospital websites.
Mr. Bennett sits on the external
advisory board of the Mayo
Clinic Center for Social Media.

Principal in the Maryland law
firm of Pecore & Doherty, LLC,
representing health systems
and individual, group and
institutional healthcare providers and suppliers. Mr. Doherty
maintains faculty appointments
at the Johns Hopkins Bloomberg
School of Public Health and the
University of Maryland Francis
King Carey School of Law.

President and Founder of Savvy
Marketing Solution, LLC. With
a combination of a clinical
background with healthcare
leadership roles, Ms. Brouillette
delivers an astute understanding and expertise in healthcare
social media. Savvy provides
physician practice and healthcare entities with strategic
marketing and business development services.

(Anne Arundel County Event
Only): Associate Director of the
Center for the study of Traumatic
Stress, Department of Psychiatry,
Uniformed Services University of
Health Services. Dr. Flynn specializes in how stress alters cognitive processes and offers clinical
interventions to support patients
and their families by adapting
communication strategies for
high stress situations instantaneously communicated via social
and digital media.

CASE: In 2012, a 65-year-old
female, current smoker with a
58-pack year smoking history
(the equivalent of one pack per
day for 58 years) underwent a
chest X-ray as part of her preoperative workup prior to left
shoulder arthroscopic surgery.
Her radiograph identified an
incidental left lung lesion.
Subsequent diagnostic chest CT
scan revealed a 2-cm, spiculated
lesion in the lateral basilar
segment of the left lower lobe
approximating the major fissure.
PET/CT demonstrated
significant hypermetabolic
activity within the left lower lobe
lesion, but without abnormal
uptake in her hilar or mediastinal
lymph nodes or other distant
sites. Since she had excellent
performance status and adequate
pulmonary function, she elected
to undergo surgical management
of her lesion that consisted
of a thoracoscopic (VATS)
therapeutic wedge excision
of the nodule followed by
completion lower lobectomy
and lymphadenectomy. Final
pathology confirmed an invasive
adenocarcinoma extending to
the visceral pleural surface with
all lymph nodes negative. She
has been undergoing routine
oncologic surveillance for her
stage 1B lung cancer for the past
18 months with no signs of
recurrence.

DISCUSSION: Until recently, efforts at
screening for lung cancer, including
sputum analysis and chest X-ray, have
failed to demonstrate a survival benefit,
even for higher-risk patients. However,
in the summer of 2011, the New
England Journal of Medicine published
the results of the NCI-funded National
Lung Screening Trial (NLST), which
demonstrated a mortality benefit of
screening high-risk persons for lung
cancer by yearly low-dose CT scan.

consumption, lung cancer remains the
leading cause of cancer deaths in the
United States, claiming the lives of
approximately 160,000 Americans
annually. In Maryland residents, the
yearly incidence of lung cancer is
approximately 3,700, accounting for
about 2,800 deaths annually.
Unfortunately, in its early stages,
lung cancer is rarely symptomatic. As
a result, it can go unnoticed for months
or years. Most people are diagnosed

In Maryland residents, the yearly incidence of
lung cancer is approximately 3,700, accounting
for about 2,800 deaths annually.
Since these landmark results were
made public, numerous medical
societies, including the American Cancer
Society, the American College of Chest
Physicians and the American Society of
Clinical Oncology, have provided
recommendations for annual screening
that closely parallel the criteria utilized
by the NLST.
Following review of the NLST results
and other ongoing related trials, the
U.S. Preventive Services Task Force
(USPSTF) recently proposed annual lung
cancer screening of long-time smokers
by low-dose CT scan. Those eligible for
screening are:
z 55-79 years of age
z Current smokers or those who have
quit in the past 15 years
z Those who have smoked a minimum
of 30-pack years
This draft recommendation from the
USPSTF is currently available for public
comment, and is expected to be formally
adopted in the next few months.
The USPSTF recommendation has
tremendous implications. Despite
generally declining rates of cigarette

with advanced-stage disease, with nearly
90% ultimately dying from their cancer.
Our patient was fortunate to have a
chest X-ray prior to shoulder surgery
that led to the incidental discovery of
her early-stage lung cancer. Clearly, she
would have greatly benefitted from
screening, as she fits the criteria
proposed for lung cancer screening.
Once the USPSTF issues a final
recommendation, it will be imperative
that all practitioners, and ultimately
patients, are educated about the role
and value of lung cancer screening.
Smoking cessation remains the most
important means of preventing lung
cancer, but we finally have an evidencebased screening method to identify
people at the highest risk. This proposed
recommendation should greatly reduce
or eliminate the need for incidental
discovery of early lung cancers, as
occurred in this patient, and will
ultimately provide an increased chance
for earlier detection, treatment and cure
for this devastating disease.
Stephen Cattaneo, M.D., is Anne Arundel
Medical Centerâ&#x20AC;&#x2122;s medical director, Thoracic
Oncology Division, and director, Surgical
Oncology.

N MARCH 23, 2010,
President Obama signed into law the
Patient Protection and Affordable Care
Act (ACA), which aims to eliminate
inefficiencies in our current healthcare
system and extend coverage by providing
affordable care to uninsured Americans.
Small private medical practices (less than
50 employees) are planning ahead for
the effects these changes will have on
their practices. Since federal agencies are
continuing to develop new rules and
guidance, practices should consult with
legal counsel for a comprehensive
explanation of the ACA and how
various regulations will apply to them.
As the owner of a small private
medical practice, you should know which
provisions taking effect January 1, 2014,
may affect the health insurance plan
currently offered to your staff, including:

Small private medical practice rates in
Maryland are currently based on the
average age of the employees enrolled in
the plan. Going forward, group rates will
be the sum of individual rates for each
enrolled individual based on their age.
Rating will no longer be based on
enrollment tiers of Employee, Employee
+ Spouse, Employee and Child, and
Family. ACA-compliant plan premiums
will be calculated based on the age of
the employee, his/her spouse and each
dependent (when applicable). For family
plans, rates will include the employee,
his/her spouse, the oldest three children
under age 21 and all adult children ages
21 to 26.

Employer Mandate

Small private medical practices (1–49
employees) are NOT subject to the
employer mandate or financial penalties.
Essential Health Benefits

Any plans sold or renewed in the small
group market (except grandfathered
plans that are renewed by December 1,
2013) will include new benefit
requirements known as Essential Health
Benefits (EHBs). Many existing medical
plans currently include these benefits,
but annual and lifetime dollar limits
have been removed. The EHBs are:
- Emergency services
- Hospitalization
- Laboratory services
- Maternity and newborn care
- Mental and behavioral health and
substance use disorder services
- Prescription drug coverage
- Rehabilitative and habilitative
services and devices
- Pediatric dental and vision coverage

Premium Increases

The ACA also introduced new fees, taxes
and assessments that may add to the cost
of health insurance plans, including:
z Federally Facilitated or State
Exchange User Fees – in Maryland,
state funding will cover this fee in
2014.
z Transitional Reinsurance Program –
All plans in Maryland will be charged
a $5.25 PMPM (per member per
month) fee.
z Patient-Centered Outcomes Research
Institute Fee – Commercial health
insurers and employer-sponsored
health plans will be assessed an
annual fee to fund patient-centered
outcomes research. This fee, which
will be imposed for a limited number
of years, is:
z $1 per covered life for the plan and
policy years ending after September
30, 2012, and before October 1, 2014
z $2 per covered life for the plan and

policy years ending after September
30, 2013 and before October 1, 2014
z Risk Adjustment Fee – All nongrandfathered small group plans will
be charged this fee, estimated at $1
for each covered life per year.
Additional fees will be applied, but the
amounts have not yet been determined
by the federal government:
z Health Insurer Fee – All plans in
Maryland will be charged this fee,
estimated at 2% to 3% of the
premium.
z QHP Certification Fees for Small
Business Health Option Program
(SHOP) – All plans in Maryland will
be charged this fee if purchasing a
plan on the SHOP Exchange.
Medicare Payroll Tax for HigherCompensated Staff

Currently, all employees pay a 2.9%
Medicare tax. According to the IRS:
z An employer must withhold an
additional Medicare hospital
insurance tax (0.9%) from wages it
pays to an individual in excess of
$200,000 in a calendar year without
regard to the individual’s filing status
or wages paid by another employer.
z An individual is liable for additional
Medicare taxes if the wages,
compensation or self-employment
income exceed the threshold amount
for the individual’s filing status:
- Married filing jointly threshold
— $250,000
- Single threshold — $200,000
Take action now to ensure that you
are prepared for the health insurance
changes coming in January 2014.
Christopher M. Rutzebeck is the benefits
manager at Human Resources inc. He can be
reached at chris@hri-online.com.

SEPTEMBER/OCTOBER 2013

|9

Profile

SPONSORED CONTENT

ACOs: Returning Joy
to the Practice of Medicine
GBMC HealthCare was
the first Maryland hospital
to partner with physicians
to create an Accountable
Care Organization (ACO)
through its affiliate,
Greater Baltimore Health
Alliance (GBHA). After
two years of planning and
initial setup, the ACO was
launched in 2012. Colin
Ward, GBHA’s executive
director, says, “We were
very deliberate in our
developmental years,
creating a physician-led
board of directors and
aligning with like-minded
providers.”
What is an ACO?
An ACO is an organizing entity that
allows providers to work in concert to
provide more coordinated patient care.
Ward provides an interesting analogy:
“We consider patients to be a movie, not
a snapshot,” he says. “The ACO can
look at the gaps in patient care and reach
out, actively engaging patients who have
multiple chronic conditions between
visits. The ACO itself is physician driven.
We assimilate clinical information and
claims data from the physicians, then
give it back to them to foster shared
decision-making.”

ACO Benefits
The true value of the ACO lies in its
ability to get real-time and retrospective
10 |

WWW.MDPHYSICIANMAG.COM

information about its
patients so that
doctors can intervene
quickly to prevent
minor issues from
spiraling into major
health crises.
Ward observes,
“It’s a mindset shift
that, if done right,
provides clear benefits
to both physicians
and their patients.
Colin Ward, GBHA’s executive director
An ACO can return
Participating physicians use electronic
joy to the practice
health record systems to share clinical
of medicine because physicians can
information among providers. The ACO
see meaningful changes in the care of
provides technical assistance to optimize
their patients.
the system, or assist practices in
“Our ACO can give participating
implementing a system from scratch.
physicians data revealing such
To participate in the Medicare ACO
information as which of their
program, GBHA had to submit
hypertensive patients are not under good
a list of tax IDs for all participating
control, or which of their patients have
physicians to determine the population of
A1C levels that are too high,” Ward
patients attributed to GBHA. As part of
continues. “We can provide the clinical
the program, CMS shares claims files that
data tied to specific patient names to
help the ACO understand patient needs,
shine a light on places where the
and close gaps in care. Notes Ward,
physician’s attention is needed.”
“Both Medicare and Cigna are providing
us with information that is vital to
properly engaging patients and caring for
GBHA ACO
Today, the GBHA ACO has slightly more them in a more proactive manner.”
GBHA chose Medicare’s single-sided
than a year of experience under its belt. It
has nearly 14,000 combined beneficiaries payment model, which provides fee-forservice payments, plus the opportunity to
in the Shared Savings Program
share in a percentage of any savings at the
established by Medicare and the Cigna
end of each year. This model provides the
Collaborative Accountable Care
group with less potential upside than the
Program. There are 100 participating
two-sided model, but no downside risk.
primary care providers, including nurse
practitioners (NPs) and physician
assistants (PAs), plus some specialists.
Building on the PCMH Model
Some providers are employed and others
The GBHA ACO builds upon the Patient
are aligned with the ACO. The entity has
Centered Medical Home (PCMH)
four care managers and is hiring two
concept. Robin Motter-Mast, D.O., a
additional ones. It also employs three
participating family practitioner in Hunt
care coordinators for managing nonValley, and member of GBHA’s board,
clinical issues.
recalls, “In March 2012, our practice

received Level 3 recognition from
NCQA. We participated in CareFirst
BlueCross BlueShield’s PCMH, which
provided a foundation for the ACO
because its metrics are similar.” The
ACO now has four NCQA-recognized
PCMH practices, and another three
under consideration.
As a PCMH, the Hunt Valley practice
had already hired care managers and
enhanced its IT capabilities to better
monitor patient care. The approaches
they were beginning to use as a PCMH,
such as greater education and monitoring of diabetic patients, provided an
excellent basis for the ACO. When they
transitioned to the ACO, they also added
new services, such as leaving 30% of
the daily schedule open for same-day
appointments to take care of urgent issues
and ensuring extended office hours.
Virtually all of these open slots are
filled each day.
The ACO entails changes on the
hospital side as well. Ward notes, “For
example, transition guides are now in
place at GBMC to follow congestive heart
failure patients and get them back to the
primary care physicians after discharge.”

From Reactive to Proactive Data
“As a pilot program with CRISP, which
runs the state’s Health Information
Exchange, the Encounter Notification
Service (ENS) has been critical to help us
better coordinate patient care,” Ward
remarks. “We get real-time notification
of hospitalizations and ED visits, so that
patients discharged from the hospital
have the opportunity to be seen in the
physician’s office within 48 hours.
“Thanks to the statewide database, we
can see if a patient has visited several
EDs in the state, for example, and can
intervene to address their medical
problem and often prevent future visits
or hospitalizations. Or, we can tell that,
while on vacation at the beach, one of
our patients had chest pain and went to
the ED in that area.”

“We’re moving
from reactive to
concurrent and
eventually proactive
data,” comments
Ward. “That’s
meaningful to patients
and doctors alike. We
can do something to
prevent an emergency
visit if we see that
patients aren’t
controlling their
Robin Motter-Mast, DO, GBHA
diabetes or other
participating family practitioner.
chronic conditions
contracts that require them to know how
well. Our care managers can contact a
their patients are doing and to intervene
patient who was seen in the ED and ask
quickly if necessary. Being aligned with an
if they need help with prescriptions or
ACO allows them to do that.”
home health. Or, they can arrange for inHe concludes, “The key is that we
home PIC line placement after a patient
is discharged, instead of having that done help reorganize and re-engineer with
small, smart and focused changes that
in the ED or hospital.”
give physicians more joy and that keep
Ward notes that the data also helps
patients healthier. Physicians are no
to shift patient thinking and behavior.
“With the ENS, we can view the patient’s longer going it alone. They get peer-topeer interaction and learning, plus
chief complaint. When we contact the
information about their practice that
patient and tell them that we could have
they can compare to other practices.
handled their problem in the physician’s
They can handle activities that need
office, not in the ED, they are often
physician intervention while the ACO
pleasantly surprised. It’s an opportunity
handles non-provider tasks.”
to educate them.”
Physicians interested in learning more
Specialists can participate in multiple
about GBHA can contact Garret Morris
ACOs and are not formally named as
by calling 443.849.4242 or by emailing
participants with GBHA. ACO referral
gbhaquestions@gbmc.org. Information
guidelines set milestones for specialty
about the Medicare Shared Savings
care, so that both the referring and
Program is available at
receiving physician agree on the plan
www.cms.gov/sharedsavingsprogram.
of care. Once the agreed-upon clinical
milestone is achieved, patients can be
returned back to the primary care office.
*www.innovation.cms.gov/initiatives/ACO/
“It frees up a specialist’s schedule so that
new patients needing initial consultations
can be seen more quickly,” Ward notes.
“One of the biggest challenges we hear
Is an ACO Right for You?
from patients and providers is the delay
Providers should have or be willing to get
in scheduling an appointment to see a
the following to participate in an ACO
specialist, and this can alleviate that.”
As reimbursement becomes increasingly
z Implement and use an EHR
tied to outcomes, Ward advises,
z Share clinical data for quality
“Physicians will have pay-for-performance
reporting
z Use evidence-based practices where
appropriate

CMS Description of an ACO
ACOs are groups of doctors, hospitals and other healthcare providers, who come together voluntarily to give coordinated, high-quality care to the Medicare patients they
serve. Coordinated care helps ensure that patients, especially the chronically ill, get the
right care at the right time, with the goal of avoiding unnecessary duplication of services
and preventing medical errors. *

Maryland Physician recently consulted with experts in breast,
lung and prostate cancer to learn the latest about appropriate
screening and treatment for these common cancers.
PROPHYLACTIC MASTECTOMIES
AND GENETIC MUTATIONS
Given that one in eight women are now at risk
for breast cancer in their lifetime, Dr. Kristen
Fernandez, breast surgeon and director of the
Breast Center at MedStar Franklin Square
Medical Center, says, “I often tell my new
patients that the two big risk factors for
getting breast cancer are being a woman and
getting older.”
Media coverage of Angelina Jolie’s
prophylactic bilateral mastectomy at age 37
heightened awareness of the role of genetic
mutations in breast cancer and raised questions
about the best course of action in these cases.
Jolie, who carries a mutation of the BRCA1 gene
and whose mother died of breast cancer at age
56, has stated that her physicians determined her
risk of breast cancer was 87% and her risk of
ovarian cancer was 50%.
Genetic mutations greatly increase the risk of
incurring breast cancer. However, Dr. Fernandez
corrects some of the misconceptions about
12 | WWW.MDPHYSICIANMAG.COM

genetic variants, noting, “Only 5 to 10% of
breast cancers can currently be tracked to gene
mutation. People come to my office worried
about their family history, but we look at whether
there’s really a clear pattern and we look at both
the maternal and paternal family history. Even
many physicians don’t realize that the father’s
side of the family is equally important in
assessing genetic risk.”

Determining Genetic Testing
Appropriateness
Dr. Fernandez continues, “The best person to
refer for BRCA testing is a living relative who’s
already had pre-menopausal or bilateral breast
cancer, or breast and ovarian cancer, not the
unaffected woman who may or may not be at
risk. If the relative with cancer tests negative
for a mutation, there’s no need to test the patient
who’s worried about their risk.
“BRCA testing is easy to perform and
typically covered by insurance, but it’s often
not appropriate,” she adds. “If the patient is

to 87%, compared to about 12% for
the average woman, and breast cancer
occurs at a younger age in these women
compared to sporadic breast cancers
in the general population. An
oophorectomy decreases breast cancer
risk by about half.”
When advising women at high risk
about the best course of action to
take, Dr. Fernandez listens to what is
important to them. “I try not to make
assumptions about what they will want.
Prophylactic oophorectomy may be a
good first surgery from a clinical
standpoint, but if the woman is not ready
to go through early menopause, but does
want a mastectomy, that may change our
treatment plan. Similarly, the decision
about using autologous tissue from belly
fat in breast reconstruction is a personal
one – it involves a second incision and
more pain, but it gives the woman a
‘tummy tuck’ at the same time.”
She continues, “And for many
women, surgery is not the best choice.
Prophylactic mastectomy and
oophorectomy are the best risk reduction
tools that we have for women with a
BRCA gene mutation, but that does not
mean that every woman with a gene
mutation has to have surgery. The
decision to have surgery such as this is
a very personal one and should not be
made without a detailed discussion of
risks, alternatives and expectations. I
use our genetic counselor extensively in
these cases. And often my patients will
go with their siblings or parents so that
several family members can have the
opportunity to hear the explanations and
ask questions of the genetic counselor.”

negative for BRCA1 or 2 gene mutations
but has a significant family history, you
don’t know what that means. We suspect
that about half of all genetically-related
breast cancers are caused by BRCA1 and
2, but there are likely hundreds of genetic
mutations that we haven’t yet identified,
and those could put the patient at risk.”
Dr. Fernandez advises that women
with the following personal or family
histories should be counseled about their
increased risk:
z Breast and ovarian cancer history
within the same side of the family

z Multiple cases of premenopausal
breast cancer in the same side of
the family
z Male breast cancer
z Bilateral breast cancer
z Those of Ashkenazi (Eastern
European) Jewish descent with
breast or ovary cancer
“The BRCA1 and BRCA2 mutations
increase the risk of ovarian as well as
breast cancer, and the former is far
harder to detect at an earlier stage,” she
notes. “The lifetime risk for breast cancer
through age 70 with BRCA1 and 2 is 50

Dr. Fernandez stresses that monthly
breast self-exam is still a critical
component of breast health. “Every
month, I see several women who found
a lump despite a negative mammogram.
Women with genetic mutations should
get a yearly breast MRI and a baseline
mammography, followed by a
mammogram every two to three years
until age 40, to minimize ionizing
radiation. Breast ultrasound is best
when there is a palpable lump or the
MRI and mammogram results disagree.”
The U.S. Preventive Services Task
Force (USPSTF) and other medical
groups now recommend chemoprevention with tamoxifen and
raloxifene for many women at highest
SEPTEMBER/OCTOBER 2013

| 13

risk for breast cancer – those 40 to 70
years of age with a family history of
breast cancer, without signs or symptoms
of breast cancer, and never diagnosed
with breast cancer or ductal carcinoma
in situ. Women with a history of blood
clots, including deep vein thrombosis,
pulmonary emboli, strokes or transient
ischemic attacks, should not be
prescribed these agents.

Amar Rewari, M.D., MBA, radiation
oncologist at Shady Grove Adventist

RADIATION THERAPY
ADVANCES IN LUNG CANCER
The top risk factor for lung cancer
continues to be smoking; smokers are at
a twenty-fold greater risk of incurring
lung cancer than non-smokers, and those
who quit after having smoked can halve
their risk. “Counseling on smoking
cessation remains critical because lung
cancer is still the primary cause of
cancer mortality for both men and
women,” says Amar Rewari, M.D.,
MBA, radiation oncologist at Shady
Grove Adventist.
Dr. Rewari is excited about two newer
developments in radiation therapy for
treating non-operable, early stage lung
cancer: low-dose rate brachytherapy
with mesh implant and stereotactic body
radiation therapy (SBRT).

Mesh Brachytherapy
While the gold standard for treating
lung cancer is a full lobectomy, many
patients aren’t good candidates for
surgery. Until lately, a wedge resection
had an 18% risk of recurrence – three
times that of a lobectomy. External beam
radiation therapy suffers from the
difficulty in limiting radiation to just the
suture line, where recurrences are most
likely to develop.

which is laid down directly on the suture
line, contains seeds with a half-life of
several days to several weeks, delivering
high dose radiation to a focused area
while sparing normal lung tissue.”
He continues, “Studies have shown this
brachytherapy procedure, which has been
used in academic centers but was not
available in community hospitals until
recently, to be very safe, without long-term
complications. It makes the results more
comparable to a lobectomy for patients
who can’t tolerate major surgery.”

SBRT
The second development is Stereotactic
Body Radiation Therapy (SBRT). This
approach, appropriate for patients with
inoperable early stage cancer, involves
immobilizing the body and using imageguided radiation therapy. SBRT can be
used only on Stage 1 lung cancer with
tumors up to 5 cm in diameter.

Prophylactic mastectomy and oophorectomy are
the best risk reduction tools that we have for
women with a BRCA gene mutation, but that
does not mean that every woman with a gene
mutation has to have surgery. – Kristen Fernandez, M.D.
However, using low-dose rate
brachytherapy during a wedge resection
for patients with Stage I non-small cell
lung cancer greatly reduces that risk of
recurrence. Dr. Rewari explains, “In this
procedure, after the tumor is removed,
the radiation oncologist gives the surgeon
a mesh sheet containing iodine or cesium
to place in the chest cavity. The sheet,
14 | WWW.MDPHYSICIANMAG.COM

Dr. Rewari describes this procedure.
“Stereotactic radiation therapy was
originally created for the brain, where
physicians used a coordinate system to
give high doses of radiation with
millimeter level accuracy. The challenge
in the lungs was finding a way to
precisely focus the radiation on a moving
target. The patient is set up with full

body immobilization and an abdominal
compression device to make each breath
more consistent, while a 4D CT takes CT
scans over 10 phases of the breathing
cycle to assess for tumor motion. For the
image guided radiation therapy we take a
mini CT scan of the lungs to pinpoint the
tumor prior to each treatment.”
He adds, “If the tumor is not close to
critical structures, we can achieve an 85
to 95% prevention of recurrence with
just three treatments, typically given
about twice a week. Tumors close to
critical structures such as the heart and
vessels may require five treatments with
a smaller daily dose.”

Concurrent Therapy for
Advanced Cancer
For advanced stage lung cancers,
radiation therapy is combined with
chemotherapy. “If patients are good
surgical candidates then chemotherapy
and radiation is given before surgery,”
says Dr. Rewari. “With radiation alone,
the median survival is 10 months; with
chemotherapy and radiation given
sequentially, median survival rates
increase to 14 months, and with
concurrent therapy, to 17 months. Recent
studies show that adding surgery could
reduce the chance of the cancer
recurring, may prevent having to treat
lymph nodes that were previously treated
electively, and reduce radiation doses,
resulting in less toxicity.”

PSAS AND ACTIVE SURVEILLANCE:
JUDGMENT IS KEY
Excluding non-melanoma skin cancers,
prostate cancer is the most common male

cancer and the second highest cause of
male cancer deaths. About 240,000 men
were newly diagnosed with prostate
cancer in 2012, and about 28,000 died
of the disease that year. While death rates
fell significantly in the early 1990s, they
have leveled off in recent years. African
American men and those with a family
history of prostate cancer including
fathers, brothers, sons, uncles and
grandfathers, are at higher risk for
prostate cancer.
Screening for prostate cancer has come
under intense scrutiny in the past few
years. Christopher Runz, D.O., a
urologist at University of Maryland
Shore Regional Health’s Comprehensive
Urology office, comments, “Until a few
months ago, the standard was to perform
a yearly digital rectal exam (DRE) and

fit all and that’s where medical judgment
comes in.”
Dr. Runz continues, “At this year’s
American Urological Association (AUA)
annual meeting, new prostate cancer
screening guidelines were announced that
call for a more individualized approach.
Physicians need to talk to their patients
about the benefits and risks of these
screening tests and give them options.
Generally speaking, we have tended to
over-treat prostate cancer in the United
States, especially in men over age 70, as
some of these men have slow growing
indolent prostate cancer. However, we do
not want to miss a higher-grade prostate
cancer in a man with a 15 to 20+ year
life expectancy. The AUA recommends
that all men age 50 to 69 talk with their
doctor to determine if prostate cancer

Studies have shown this brachytherapy procedure… to be very safe, without long-term complications. It makes the results more comparable
to a lobectomy for patients who can’t tolerate
major surgery. – Amar Rewari, M.D., MBA

their healthcare provider to determine
appropriate steps.
z Men aged 55 to 69 have the greatest
benefit of routine screening. They
should talk to their healthcare
provider about the risks and benefits
of prostate cancer screening to
determine what is best for them.
z In men who wish to be screened for
prostate cancer, the AUA now
recommends a PSA and DRE every
two years.
“Asymptomatic men aged 55 to 69
and worried or at-risk men under 55
derive the greatest benefit from being
screened,” advises Dr. Runz. “I
recommend that primary care physicians
discuss the benefits and risks with their
patients, understanding that these tests
may detect prostate cancer earlier, help
them live longer and avoid problems
from the cancer. However, testing also
can involve false negatives and positives,
or diagnose a slow growing indolent
cancer that may never cause a problem
for the patient yet whose treatment
could entail side effects.”

Active Surveillance Guidelines
prostate specific antigen (PSA) test on
men from age 50 to 75 or 80, depending
on their overall health and life
expectancy. Last year, the U.S. Preventive
Services Task Force (USPSTF)
recommended that PSAs shouldn’t be
performed as community or employerbased screenings, but one size doesn’t

screening is right for them.”
General screening guidelines
recommended by Dr. Runz include:
z Men aged 40 to 54 years old should
not get routine PSA screenings, but
those who are having urinary changes
or other concerns should talk with

New studies support active surveillance
as an appropriate approach for a select
population. Dr. Runz notes, “A patient
with a normal digital rectal exam (DRE)
plus a Gleason Score of 6 or less is
typically appropriate for this approach.
I also consider the patient’s life
expectancy and comorbid conditions.
The first conversation we have is
whether we need to treat the prostate
cancer. I tell many of these patients with
low-grade, low-volume prostate cancer
that it’s not a short-term threat and may
not be a long-term threat to them. I’ve
found that providing articles, books and
online videos also helps to educate my
patients about low-risk prostate cancer
and make thoughtful, shared decisions.”
A Johns Hopkins study published
online in the Journal of Clinical
Oncology on June 17, 2013, found that
African American men were at higher
risk of upgraded cancer than white men
when undergoing surgery after active
surveillance, suggesting that active
surveillance could be riskier for this
population.
Guidelines for active surveillance
call for PSA/DRE exams every three
months for the first year, followed by a
second biopsy. At the end of that first
SEPTEMBER/OCTOBER 2013

| 15

year of surveillance until about age 80,
exams should be performed as needed,
with follow-up biopsies every three to
five years.
“About 25% of our active surveillance

Oncotype DX Genomic Prostate Score
(GPS) as a new genetic test. “It’s a good
option for men on active surveillance,”
remarks Dr. Runz. “We send a specimen
from the biopsy to a specialized lab.

Asymptomatic men aged 55 to 69 and worried or
at-risk men under 55 derive the greatest
benefit from being screened. – Christopher Runz, D.O.
patients eventually go on to have
treatment if their repeat biopsy shows
a change in their prostate cancer,”
Dr. Runz says. “We readdress curative
treatment options with them if they have
a grade or stage migration after a repeat
biopsy and they’re appropriate
candidates. This may mean continuing
active surveillance or surgery or radiation
therapy. It is important to ensure that
this is a shared decision-making process
with the patient and family so they fully
understand the risks and benefits of each
option, including understanding the
natural history of their particular
prostate cancer.”
In May 2013, the FDA approved

GPS is a measure of the activity of 17
genes within the tumor and can help
to predict the aggressiveness of the
patient’s prostate cancer. This test is only
meant for low to intermediate grade
prostate cancers, so it’s a good option
for men who are on or considering active
surveillance. This test can help those
patients without high-grade-disease
personalize their treatment based on their
cancer genetics.”

New Treatment for Advanced
Prostate Cancer
Men under age 65 with metastatic,
castration-resistant prostate cancer
who have failed radiation therapy or

surgery often are referred for androgen
deprivation therapy (ADT). This
hormonal therapy typically halts the
cancer progression for 18 to 24 months,
but is not a cure. Until recently, the
only other therapeutic option was
docetaxel based chemotherapy. However,
two new drugs – Xtandi (enzalutamide)
and Zytiga (abiraterone) can block
testosterone receptors and stop
testosterone production earlier in the
cascade, providing promise for men
with prostate cancer resistant to
hormonal therapy.

Clinical Features
Maryland Physician spotlights the latest innovations in
clinical care and treatment delivered by your Maryland
peers and colleagues as well as advances in medical training which facilitate achieving the highest standards of
quality care and practice management solutions.

Healthcare IT
In every issue, Maryland Physician explores a different
facet of the race to implement EHRs to meet Meaningful
Use and other e-health government incentives. Don’t be
left behind – read what Maryland physicians and healthAs a leader in the field of medical practice
management, SHR Associates, Inc. delivers
consulting and practice management services to
physicians and healthcare organizations. We
provide the business resources and tools to help
physicians prosper in today’s dynamic healthcare
Proudly serving
the physician community
for over 30 years!

and second opinions to physicians and their patients.
Dr. Lewis M. Levy, Vice President of Corporate
Medical Quality at Best Doctors, explains how the
company’s innovative service is an incredibly valuable
resource for physicians in a patient-centered medical
home or accountable care organization.
Q: Why is Best Doctors a valuable resource for practices
using PCMH payment models?
A: Our services enable the physician to regain more control of the consultation process and may help the practice
earn more payment incentives. In brief, our service is
designed to:

Q: How does Best Doctors support the patient-centered medical home (PCMH)?
A: When a physician faces a challenging case, he or she
can contact Best Doctors and receive a well-researched,
evidence-based second opinion from a nationally-recognized specialist. This isn’t a utilization review. It is a superb
and timely resource for doctors and a powerful way to
improve patient outcomes and satisfaction.

Q: Who are the Best Doctors expert specialists?
A: Our specialists are chosen via an impartial, nationwide
poll of physicians that asks doctors who they would see
for their own care. Specialists are practicing physicians
and often affiliated with leading centers of excellence. Our
polling process is Gallup reviewed and certified.

Q&A with Lew M. Levy, MD

Q: How can Best Doctors improve upon the professional network doctors have already established?
A: The Best Doctors service provides an expert second opinion, typically in much less time than it takes to schedule an
appointment at a specialty or teaching hospital. In addition,
Best Doctors often provides treating physicians with a complete and comprehensive medical history of their patient.

Q: Why does Best Doctors work to support physicians
in this way?
A: Our service is financed by large employers and health
plans as a part of their employee/member benefits offerings.
Therefore, our objective is to support physicians in finding
the right diagnosis and treatment for these patients.

About the Interviewee
Dr. Lewis Levy is Vice President of Corporate Medical Quality at Best
Doctors. The mission of Best Doctors is to provide the right diagnosis
and right treatment to patients. The company provides medical
consultations by connecting patients’ physicians
to the best expert specialists in the world. Dr.
Levy provides medical leadership to the clinical
operations team. He has over twenty years of
clinical experience as an internist at Harvard
Vanguard Medical Associates in Boston and
is also as an Instructor at Harvard Medical
School. He earned his medical degree from
the University of Rochester School of Medicine
and Dentistry and completed his residency in
Internal Medicine at the Graduate Hospital of
the University of Pennsylvania.

LEARN MORE AT: www.BestDoctors.com/MarylandMD1

Harnessing the

POWER
of Imaging to Fight Cancer
Imaging modalities play an important role in the early
detection and monitoring of cancer. Maryland radiologists
describe how advances in 3T MRI and PET/CT are
improving oncologic imaging. By Linda Harder

NOPR DEMONSTRATES VALUE
OF ONCOLOGIC PET/CT
The value of PET with F-18
fluorodeoxyglucose (FDG-PET) in
oncologic diagnosis and treatment
planning was demonstrated resoundingly
in the National Oncologic PET Registry
(NOPR), which began in 2006.
After the initial NOPR data was
analyzed, in 2009 the Centers for
Medicare and Medicaid Services (CMS)
expanded coverage for FDG-PET
scanning for Medicare beneficiaries
diagnosed with cancer. The NOPR
continued to collect data for many
remaining cancer indications. The 2009
CMS ruling provided reimbursement for
PET scans used in the initial evaluation
of patients with most types of solid
tumors, and allowed for PET in
subsequent evaluations for an expanded
number of cancer types.
Ethan Spiegler, M.D., chief of Nuclear
Medicine at Advanced Radiology and
chair of Nuclear Medicine at Saint Agnes
18 | WWW.MDPHYSICIANMAG.COM

Hospital, notes, “Since 2006, almost all
solid tumors have been approved for
initial diagnosis with PET.”
In 2011, based on a February 2010
National Coverage Decision, the NOPR
began collecting data on Medicare
patients undergoing PET with sodium
fluoride-18 (NaF-PET) to evaluate bony
metastatic disease. Dr. Spiegler
comments, “While FDG-PET has proven
to be an excellent tool for soft tissue
information, the registry is still used to
compare sodium fluoride bone scans to
NaF-PET. I think the results are likely
to show that PET is useful for bone
metastasis, common in prostate cancer.”
Beginning in early 2013, CMS allowed
physicians to order up to three FDG-PET
scans after the completion of initial
therapy without having to submit data
to NOPR. Local Medicare contractors
must determine whether subsequent
scans will be covered. The CMS decision
was applauded by PET advocates,
including the Society of Nuclear

Medicine and Molecular Imaging and
the Medical Imaging & Technology
Alliance (MITA).
Dr. Spiegler notes, “Referring
physicians no longer need to complete
NOPR paperwork to refer patients for
PET/CT. While not perfect, NOPR is
considered a successful model that is
likely to be replicated in the future. It
gathered evidence from more than
100,000 scans to show that PET
positively affects patient management.
In the scheme of things, even though
it’s an expensive technology, it was
found to save dollars and lives.”
CMS also added prostate cancer as
a clinical indication for PET this year.
Dr. Spiegler cautions, however, “In
prostate exams, PET/CT is not
appropriate for the initial diagnosis,
although it has a strong role to play in
guiding the management of advanced
prostate cancer.”
He adds, “Myeloma also just got
coverage approval this year. And we are

now researching whether using FDG
and NaF during the same PET/CT scan
can be used in place of a bone scan plus
other modalities. The only added cost
of this approach would be the second
isotope.”

NEWER RADIOISOTOPES
SHOW PROMISE
In September 2012, the FDA approved
the production and use of C-11 choline
in PET as a result of its effectiveness
in detecting recurrent prostate cancer.
It is appropriate for patients previously
treated for prostate cancer who have
elevated prostate-specific antigen
(PSA) levels.
New isotopes for determining whether
or not prostate cancer is confined to
the gland are also in the research and
development stage. According to Dr.
Spiegler, “No modality does that well
yet. It’s not clinically available today,
but studies look promising.”
A Johns Hopkins study published
recently in the Journal of Nuclear
Medicine gives preliminary hope that
a new small molecule radiotracer (18FDCFBC) can be used in PET scans to
visualize metastatic prostate tumors.
Rather than using an analogue of
glucose labeled with 18F-fluorine,
the study attached 18F-fluorine to
DCFBC, the small-molecule compound
they manufactured that can target the
prostate-specific membrane antigen
(PSMA) found in prostate cancer, and
vasculature found in other types of
solid tumors.
Because 18F-DCFBC targets PSMA as
it protrudes from the cellular membrane
of the tumor, it highlights cancerous soft
tissue, such as that in lymph nodes. And
its ability to directly target the tumor site
appears to enable it to pick up lesions
not seen on conventional bone or CT
scans because they haven’t yet resulted
in local bone destruction.

ONCOLOGIC 3T MRI
“A very important contribution 3T MRI
has had in oncologic imaging is the
enhancement of MR spectroscopy,” says
Elias Melhem, M.D., John Dennis
chairman of the Department of Diagnostic
Radiology and Nuclear Medicine at the
University of Maryland Medical System.
“The enhanced signal-to-noise ratio of 3T
helps because it can detect metabolites
despite their low concentration. 3T also
provides better spectral resolution that

allows us to tease out the metabolites that
are significant in cancer.”
3T spectroscopy not only distinguishes
cancer cells from benign tissue, but it can
also determine how aggressive the tumor
will be.
Another advantage of 3T in oncologic
imaging entails Susceptibility Weighted
Imaging (SWI). SWI has developed into
a powerful clinical tool used to visualize
venous structures and blood products in
the brain and to study a range of
pathologic conditions. It provides
complementary information to that
offered by spin density, T1 and T2.
Dr. Melhem explains, “SWI is
implemented much better at 3T. We can
detect metastatic breast cancer at a much
earlier stage, for example.”

3T MRI FOR PROSTATE CANCER
3T MRI is used in conjunction with
ultrasound in staging prostate cancer, to
determine if the cancer has extended
beyond the capsule. It can also be used
in computer-assisted 3D MRI/Ultrasound
Fusion Biopsy to create a more targeted
biopsy in men who have had a negative
biopsy but a rising Prostate-Specific
Antigen (PSA), or men diagnosed with
prostate cancer who are undergoing
active surveillance. Radiologists and
urologists combine efforts to fuse an

it requires that a smaller 5T magnet be
available in a room adjacent to the 3T
magnet. “The C-13 is cooled to nearly
zero degrees Kelvin,” Dr. Melhem notes.
“The 5T magnet is used polarize the
contrast agent. As soon as it’s polarized,
it is brought into the room with the 3T
magnet and the patient, and then
injected. When using C-13 in humans,
it must be sterile, which makes the
technique expensive.”

TREATING BRAIN TUMORS
WITH 3T
3T MRI is also starting to be used in
conjunction with focused ultrasound to
treat brain tumors. “We will be the first
in Maryland to use MRI-guided focused
ultrasound to detect changes in brain
tissue temperature,” states Dr. Melhem.
“We will use MRI to localize the tumor,
then use the ultrasound to heat and
destroy cancerous tissue. It’s useful with
primary tumors or metastastic disease, as
well as epilepsy. We will be involved in
Phase III trials of essential tremors. We
would heat up an affected area, watch
that the tremors improved, and know
that we had targeted the right tissues.”
Dr. Melhem predicts that in the next
year or two, 3T MRI will be able to
target tissue in the breast and prostate
using much the same approach. He

…NOPR is considered a successful model that is
likely to be replicated in the future. It gathered
evidence from more than 100,000 scans to show
that PET positively affects patient management.
– Ethan Spiegler, M.D.

MRI image onto a live 3D ultrasound
image to create a Doppler ‘map’ that
pinpoints the location of potential
tumors and replaces the current random
template biopsy.
The near future of 3T MRI holds even
more excitement. “The future is in MR
Imaging with Carbon 13 labeled 3pyruvate, and UMMC will be one of the
first to get it,” enthuses Dr. Melhem.
“We will be part of a multi-center trial
led by University of California San
Francisco that will observe metabolic
activity in prostate cancer to determine
who is appropriate for watchful waiting
and who is not. The challenge has been
how to accurately classify patients.”
The new approach may be limited to
academic centers with deep pockets, as

concludes, “PET/CT and 3T MRI play
complementary roles in detecting
metastatic disease. MRI is most useful in
peering into the brain to find evidence of
metabolites, while PET/CT is excellent
throughout the body. Together, they
provide nearly complete surveillance.”

Elias Melhem, M.D., the John Dennis
chairman of the Department of
Diagnostic Radiology and Nuclear
Medicine, University of Maryland
Medical System
Ethan Spiegler, M.D., chief of Nuclear
Medicine, Advanced Radiology and
chair of Nuclear Medicine, Saint
Agnes Hospital

SEPTEMBER/OCTOBER 2013

| 19

Profile

SPONSORED CONTENT

Lessening the Pain of an EHR
Upgrade or Purchase

W

HY IS AN EHR
purchase or upgrade so often painful –
and for so long after its initial purchase?
And does it have to be? James Milligan,
CEO of Medical Mastermind, who has
seen many physicians that are still
putting in long hours, long after their
EHR implementation, believes it should
not be so painful.
He says, “We’ve seen some doctors
that were still carrying both paper and
electronic charts around for months.
They were disenchanted because the
EHR had not delivered on the paradigm
it had promised – that it would be easier
and better than paper and that they
could see more patients. It was true that
staff no longer hunted for records and
that pharmacy orders could be delivered
electronically, but otherwise it was
more, not less, painful.”
While it’s also painful to abandon
the many hundreds of hours and
thousands of dollars invested in an
existing EHR, the failure to deliver on
promised efficiencies is one of the
reasons that many physicians are now
looking to change their EHR system.
“Some of the newer systems are
delivering on their promises,” Milligan
says. “They are focusing on work flow,
ease of use, being intuitive, decreasing
20 |

WWW.MDPHYSICIANMAG.COM

James Milligan, CEO of Medical Mastermind

the number of clicks and being available
on mobile devices such as an iPad.
These products are finally delivering
on the paradigm that was promised.”
Suggested questions to ask when
evaluating a new EHR purchase or
an upgrade follow.
Is It Designed With Physician Input?

The desire to have an integrated system
based on the way physicians actually
practice motivated Software Unlimited
Inc. to merge with Integrated Health
Care Solutions (IHCS) in early 2013
and rename the company Medical
Mastermind. Milligan explains why
IHCS was selected out of 200 practice
management companies they had
considered. “IHCS was launched
when a group of EHR designers got
together with five dissatisfied physicians
and several programmers to create one
of the few EHR systems that meet

physician needs. They worked together
to create a system that was easy to
use, facilitated physician workflow
and reflected the way each of the
doctors actually practiced medicine.”
“Of course, any EHR represents a
big change and involves change
management,” Milligan acknowledges.
“But it should not make things more
difficult, and after the start-up period,
it should greatly reduce the time
physicians spend charting so that seeing
more patients is a natural consequence
of using their EHR.”
The company, which is headquartered
in Pikesville, MD, has more than 1,500
customers in the U.S. and about 250
of those are using the new EHR – we’re
the fastest growing EHR vendor in the
U.S.,” Milligan comments. “We do all
of our implementation on site and our
local staff provide service throughout
Maryland.”

Does the EHR Specialize in Your
Specialty?

One of the questions to ask an EHR
vendor is whether their system can
accommodate the needs of your medical
specialty.
“Medical Mastermind can be used
by all specialties, but we have seven that
we do exceptionally well, including
primary care, pediatrics, orthopaedics,
otolaryngology, podiatry, urgent care
and chiropractic,” Milligan states.
Does the EHR Accommodate
Variations in Practice Style?

One of the greatest challenges EHRs face
is accommodating variations in the way
physicians practice – even within the
same group. Jody Harbour, Medical
Mastermind’s chief designer and VP of
Product Development, recalls, “One of
our practices has seven surgeons; while
they’re all in the same location, they
practice medicine in seven different ways.
Our system was the only one they found
that allowed them to keep practicing
individually. For example, one physician
wanted a templated (a pre-defined tool to
capture and organize clinical data within
the system) approach, while another
preferred the narrative approach. We
found a way to incorporate the narrative
approach while still maintaining
compliance. We spent a long time
learning from the physicians and then
applying what we learned to our system.”
Mark Brown, M.D., FACS, was
initially the most reluctant physician in
his ENT practice to convert to an EHR.
However, after rejecting a number of
EHR systems, he found he was impressed
by Medical Mastermind’s willingness to
learn from him. “My attraction to the
system was that they said, ‘we’re going to
make this work the way you practice
now,’ not, ‘you have to practice the way
we’re going to make this work.’’’ After
becoming one of the system’s biggest
advocates, Dr. Brown retired and went
on to become the medical director for
Medical Mastermind.
The Medical Mastermind EHR system
is easy to adapt to the needs of a given
physician because it has a series of
‘switches’ that can be turned on and off.
That makes it flexible without requiring
an expensive or labor-intensive custom
solution. Mastermind EHR arrives fully
integrated with PM and Billing, and uses
a permissions-based system to allow

access to various functions depending
on the user. For example, to enable
the complete Practice Management
suite, settings are changed by Medical
Mastermind once the licenses are
purchased, eliminating the need for
additional software installation or
integration.

PM are appropriate for the solo
practitioner, but easily scalable to a
practice with 50 practitioners or more in
multiple locations. “We have experience
with both solo physicians and larger
groups, whereas legacy products usually
become too complicated when you try to
scale them down,” Milligan notes.

Does the EHR Offer Integrated
Practice Management?

Does the EHR Offer a Robust
Patient Portal?

Another reason to replace an EHR
includes needing a system with integrated
practice management (PM), rather than
one that was retrofitted, or two separate
software programs attempting to share
data. According to Milligan, “Many
vendor companies focused solely on their
EHRs, but that created inefficiencies
when they tried to integrate the system
with practice management. Without a
single, integrated database, you lose
information on scheduling, patient data,
billing and so on.”

Meaningful Use Stage 2 will make patient
access to their data and communication
between providers and patients more
critical. Patient portals have proven to be
an effective way of achieving some of the
Stage 2 milestones as well as a time-saver
for physicians and patients.
Satisfied user Darmesh Bhakta, DPM,
comments, “The patient portal is a huge
benefit for us. It saves time, especially if
patients can fill out their medications and
dosages at home. We get a more
complete picture of the entire patient that

….any EHR represents a big change... But it
should not make things more difficult, and after
the start-up period, it should greatly reduce the
time physicians spend charting so that seeing
more patients is a natural consequence of using
their EHR. – James Milligan, CEO
Peter Whitehead, M.D., a pediatrician
whose group uses Medical Mastermind,
notes, “They have helped us, from a
physician practice standpoint and an
operational standpoint, to manage our
monies going in and out, manage our
visits in, manage our patients to optimize
healthcare and to optimize revenue for
the practice.”
Can You Choose Between Client Server
and Cloud-Based Systems?

As discussed in the Nov/Dec 2011 issue
of Maryland Physician (Should You Store
EHR Data Onsite or Offsite?), physicians
have to determine whether a server-based
or cloud-based EHR approach makes the
most sense for their practice. Milligan
notes, “A big part of our acquisition of
IHCS was that it enabled us to offer
physicians the choice of either approach.
Also, if the doctor wants us to handle his
or her billing, we can offer that as part of
our services.”
Mastermind EHR and Mastermind

way. The patient portal helps us to be
more complete. Now we feel like we
have triple-checked their data. The
patient checks it, our medical assistant
and I check it, and we have an entire
history – and it’s correct.”

Medical Mastermind, established in
1984, provides Electronic Medical
Record and Practice Management
solutions to thousands of physicians
from all specialties. Its award-winning
software (including its recent award as
the 2013 Black Book award for #1 Top
Rated EHR for Otolaryngologists, and
inclusion in Capterra’s 2013 list of the
Top 20 EHRs in the country) is
designed by doctors, nurses, billing
administrators, and other medical
personnel to provide the ideal
solutions for any size practice and
every specialty. For more information,
visit www.medicalmastermind.com.

Maryland Health Connection:
A New Insurance Marketplace
As this issue went to
print, the date to
launch enrollment for
families and individuals
in Maryland Health
Connection was
looming for Executive
Director Rebecca
Pearce and her staﬀ.
Ms. Pearce talks about
how this new service
will change healthcare
coverage for many, as
well as its potential
impact on physicians.

Q:

What is Maryland Health
Connection? The Health Connection

is a new health insurance marketplace
designed to make it easier for
Marylanders to shop for, compare and
purchase quality health coverage. We’re
not federal health insurance; we’re the
conduit – the “store” – for carriers to
put their products on our shelves. A
single, streamlined application
determines eligibility for Medicaid or
private insurance. Consumer assistance
will also be available through our call
center or in person throughout the state
in local health departments, departments
of social services and a network of
consumer assistance organizations
known as “Connector Entities.”
24 | WWW.MDPHYSICIANMAG.COM

started early compared to many states,
we had lots of policy decisions to make.
And, we had to set up an entire
organizational structure – we started
with just me. Today, our state agency
has grown to more than 50 people.

Q:

Who do you expect will
purchase insurance in the Health
Connection? The first year, we expect

about 250,000 newly eligible people to
enroll, which includes about 100,000
people who will be newly eligible for
Medicaid when it expands from 116%
to 138% of the federal poverty level.
Maryland Health Connection will
determine if a person qualifies for
Medicaid or commercial insurance.
At the end of 2015, we expect that all
of the 1.2 million people on medical
assistance will use the marketplace.

In Phase 2, our long-term goal is to
have the non income-based Medicaid
population go through it as well – that
is, long-term care, disability and also
social services.
We’ve done 12 focus groups around
the state. There’s a misnomer that people
don’t want health insurance. We found
that people want to have health
insurance and want to know that they
can see a physician when needed. When
we presented them with a price and the
value of the insurance they would get
through Maryland Health Connection,
and what the federal subsidies might be,
they were willing to give up amenities
like their cable television to get health
insurance.

Q:

Which insurers are participating
in Maryland Health Connection?

Currently, we are working with
CareFirst BlueCross BlueShield, Kaiser

Permanente, United HealthCare and
Evergreen Health Cooperative. The 2011
legislation requires that insurers making
a certain dollar level outside of the
exchange must participate in Maryland
Health Connection. We’re also hoping to
see MCOs [Medicaid Managed Care
Organizations] starting in 2015; they’ll
need to obtain a license first.

Q:

Discuss the rates that will be
charged under the Health Connection.

Maryland’s rates are among the lowest
of the 12 states with approved or
proposed rates – on a dollar-to-dollar
basis, they’re lower than all but one plan
in New Mexico. New York, for example,
decreased their rates 50% but they are
still higher than ours. And three out of
four Marylanders are expected to qualify
for federal tax credits.
You can’t do an apples-to-apples
comparison to rates in the past year
because this is the first year that we
will be offering essential health benefits
under the new marketplace due to the
ACA. Because of self-selection, the
individual market has historically had a
lean set of benefits. It’s like comparing
buying a hatchback to buying a sedan.
Everyone is hoping the marketplace
will attract younger people. They are
often overlooked as the people who will
get subsidies through the marketplace,
but because many of them are not
making large salaries, they will benefit.
The federal subsidies apply to
individuals making up to $44,000 a
year. Someone making the federal
poverty level of about $22,000 will pay
a maximum of 6.5% of their income,
or about $114 per month, out of
pocket for insurance because the federal
government is giving subsidies.
We don’t control the fee schedules that
carriers pay providers, but they should
be similar to other fee schedules.

Q:

For physicians who run small
businesses, what are the options and
requirements? The Small Business

Health Options Program (SHOP) will
open in January 2014 and provide small
businesses a choice of quality insurance
plans and carriers. Companies with up
to 50 employees are eligible, but not
required, to purchase insurance through

Maryland Health Connection. There is
no penalty for employers of this size.
And the federal government just said
that there is no penalty for any size
employer in year one.
Employers can only access federal
tax credits if they purchase coverage
through SHOP beginning in 2014.
Our website includes a Small Business
Tax Credit Calculator to help them
determine if they qualify for a tax
credit for providing insurance for
employees.

Q:

Will those using Maryland
Health Connection be able to see their
doctor? In fact, we created the ability to

search online for a list of participating
health plans by doctor. You can bring up
all of the plans that include your doctor.
We’re the only place you can do that.

Q:

How will providers be affected?

We would love to partner with the
physician community; we recognize that
they’re going to be touching the people
we’re bringing in. We want to understand
from them what they are seeing. They
may see an influx of people who may not
be used to using primary care. So there
may need to be some education on their
part – for example, they may see a
40-year-old who has used ERs, not a

Q:

How will you educate and enroll
the 180,000 people that you anticipate?

We have multiple ways to enroll people.
The first way is through insurance
brokers. About 1,500 insurance
brokers in the state have provided
notice of their intent to use our
Health Connection. They have to be
licensed by the Maryland Insurance
Administration to participate, and
authorized by us to sell through
Maryland Health Connection. With
about 180,000 newly insured people,
it’s a growth opportunity for brokers.
We’ve been partnering with them since
2011 – we want to supplement them,
not replace them.
We also are establishing a customer
support center with a toll-free number,
and we awarded grants to six consumer
assistance organizations (Connector
Entities) statewide to provide individual
enrollment assistance. They will reach
the underserved and hard-to-reach
populations, including those with
disabilities.
We’re hiring a total of 300 people to
provide in-person assistance; 150 of
whom are navigators who provide
education and outreach, as well as
enrollment in both Medicaid and
qualified health plans. The remaining
150 people are known as assisters; these
individuals also conduct education and

The Small Business Health Options Program
(SHOP) will open in January 2014 and provide
small businesses a choice of quality insurance
plans and carriers. – Rebecca Pearce
primary care physician, to date.
We are working directly with FQHCs
[Federally Qualified Health Centers]
and community providers, and especially
the mental health providers to let them
know that, as people get insured, they
need to contract with the carriers in
Maryland Health Connection, and here’s
what you need to do to change your
business model. And we’re talking to the
carriers as well. We’ve been trying to
bridge that gap between those two sets
of providers. And the governor’s office is
working to address provider shortages.

outreach. They can also enroll people
in Medicaid, but not private insurance.
We are also working with the
Department of Health and Mental
Hygiene and Department of Human
Resources to train the caseworkers and
eligibility workers in the local health
departments and departments of social
services statewide. These 2,500 people,
who currently enroll people in
Medicaid, will receive in-depth training
on the use of Maryland Health
Connection and enrollment.
(continued on page 29)
SEPTEMBER/OCTOBER 2013

| 25

Healthcare IT

H e a lt H i n f o r m at i o n e xc H a n g e s :

THE NEXT
HURDLE
EHR adoption has skyrocketed, but can disparate systems talk to each other?
Health information exchanges (HIEs) are beginning to bridge the gap;
Maryland is ahead of many states and stands to weather the
loss of HITECH Act funds beyond 2013 better than most programs.

LINDA HARDER • PHOTOGRAPHY BY TRACE Y BROWN

T

HE HEALTH INFORMATION
Technology for Economic and Clinical
Health (HITECH) Act made electronic
health records (EHRs) nearly
ubiquitous. According to a 2012 survey
by the Centers for Disease Control and
Prevention, the percent of physicians
using an advanced EHR system climbed
from 17% in 2008 to more than 50%
by 2012, and over half had received an
incentive payment for meeting Stage 1
of Meaningful Use.
Similarly, the survey found that
hospital adoption of EHRs grew from
9% in 2008 to 80% by 2012. But as
Meaningful Use Stage 2 looms on the

To encourage electronic sharing of
patient information, the State HIE
Cooperative Agreement Program has
helped fund state and regional efforts.
With funds from this national program,
as well as state funding, Maryland
formed a statewide HIE called the
Chesapeake Regional Information

System for our Patients (CRISP), a notfor-profit membership organization that
became operational in September 2010.
CRISP is in a better financial position
than many HIEs, with a combination of
state, federal and hospital funding. “We
have less than one year left of federal
funding,” David Horrocks, CRISP CEO,
comments. “But they are only about
15% of our HIE budget. I’m confident
that we have a revenue model that will
allow us to continue our work.”
A 2013 status report from the Robert
Wood Johnson Foundation, Health
Information Technology in the United
States, found that, in contrast to
Maryland, where all acute care hospitals
participate in CRISP, nationally only
30% of community hospitals
participated in HIE during 2012. And
only 10% of operational HIEs supported
six Stage 1 Meaningful Use measures for
information exchange. Not surprisingly,
the use of HIE by physician practices
was much lower, with 10% reporting
participation in 2012 compared with
3% in 2010.
Adam Weinstein, M.D., nephrologist
and medical director of the Eastern
Shore ACO, says, “In Maryland, the
information is centrally controlled,
which gives us better control and
standards than in states such as Utah,
which has an Intermountain Health
HIE that is not statewide. The goal of
sharing data is the Holy Grail.”
Now that all hospitals and a number
of key radiology and laboratory
providers have had ample time to
contribute data, the next step in the
arduous process of achieving
interoperability is to provide more
electronic information about hospital
admissions, discharges and emergency
visits to physicians, so that they can
follow up with outpatient care as
appropriate.
Horrocks says, “We have three
services – Query Portal, Encounter
Notification Service (ENS), and
Reporting for Quality Initiatives. We’re
happy to help physicians start on a
process to use the ENS or Query Portal.”
Query Portal Service

Comments Horrocks, “The Query

Portal currently receives about 15,000
queries a month and that number is
doubling roughly every six months. The
typical user is an ER physician or other
physician in the hospital setting, but
physicians in ambulatory settings can
also take advantage of this service once
they are credentialed.”
The portal allows clinicians to
enter a patient name and view prior
medical records (chiefly from prior
hospitalizations) and also a growing
amount of lab and imaging data. “In
the last month, we’ve added several new
feeds from hospitals, such as new lab
results. Our goal is to have more than
90% of all possible feeds by this fall,”
Horrocks notes.
Craig Behm, executive director,
MedChi Network Services, explains,
“The doctor can query the hospital
where his patient was discharged for
lab values and other data, as available.
It’s a work in progress, though Maryland

opiod use data into physicians’ hands,
to support the Prescription Drug
Monitoring Program.”
CRISP is seeking to deploy single-signon between hospitals and practice
EHRs and the Query Portal, so that
credentialed doctors can quickly access
patient information. Today, the patient’s
name and address must be entered
manually, taking up valuable time, and
adding the risk of human error.
Encounter Notification Service

A newer CRISP service that went live
in August 2012 is the Encounter
Notification Service (ENS), which
provides messages to participating
physicians when their patient visits the
emergency department (ED), or is
admitted or discharged to a hospital.
Physicians can select the services for
which they want to receive notification.
Behm observes, “Any physician
practice can participate in ENS. The

David Horrocks, CRISP CEO

is at or near the top of connectivity
compared to other states.”
“The Query Portal is used primarily
when the doctor is in a treatment
encounter, to help him or her make
the best decision,” says Horrocks.
“And we’re now partnering with the
Department of Health and Mental
Hygiene to get pharmacy data on prior

physician panel sends a list of patients
to CRISP, and CRISP assigns those
patients to a doctor. That doctor can
select what data he or she wants to get.
It involves an open source, secure
message platform through a web portal.
All of the data is free.”
“About 700 physicians have signed
on, mostly primary care physicians,”

SEPTEMBER/OCTOBER 2013

| 27

Healthcare IT
Secure Messaging to Connect Providers

CRISP also offers DIRECT Messaging, a
secure and encrypted email service that
supports electronic communication
between physicians, nurse practitioners,
physician assistants and other
healthcare providers. This service
continues the goal of securely sharing
a patient's clinical information among
their treating providers in Maryland.
Currently, DIRECT Messaging is free
for the first year.
However, secure messaging is not yet
widely used. Dr. Weinstein notes that
electronic communication between
primary care physicians and specialists
has a long way to go. “The challenge is
to make the data HIPAA compliant.
It’s far from the panacea envisioned,
so most doctors are still faxing
information. The staff has to print out
the faxed data; I manually sign it and
send it back.”
Craig Behm,
executive director,
MedChi Network
Services

says Horrocks. In large practices, the
notification may go to the care
coordinator, who channels information
to the appropriate physician. The data
can also be downloaded in a spreadsheet, so that information can be sorted.
Practices can choose to receive one
summary email early each morning
to provide information on all patients
that can be incorporated into their
daily routine.
“It’s a good fit for physicians in a
Patient Centered Medical Home or
Accountable Care Organization (ACO),”
Horrocks adds. “And Medicare has new
CPT codes that reimburse physicians for
timely follow-up care, so this service
potentially enhances a physician’s
revenue stream.”
Quality Initiative Reporting

Quality initiative reporting is the newest
aspect of CRISP’s data, operational since
January 2013. It provides inter-hospital
readmission reporting, so that a patient
discharged from one hospital and
readmitted elsewhere within 30 days can
be tracked. The ER Bounce-Back report
is being rolled out this fall, so that
hospitals can track when discharged
patients return to the ER within 72 hours.
28 | WWW.MDPHYSICIANMAG.COM

Getting Data to the ‘Last Mile’

As a provider trying to take the data
available from CRISP and put it to
work for an ACO comprised of many
individual practices, Dr. Weinstein has
a unique perspective. “At the moment,
we’re simply reporting the data, but our
ACO is about to get CRISP data. We’ll

clearer about what data we need. We’re
focusing on things we think will impact
our cost and reporting on them. Our
ACOs are a microcosm of the industry.
It comes back to how you get different
EHR vendors to talk to each other.”
Behm contributes, “MedChi would
like to see Maryland have almost a state
utility model for interoperability. CRISP
has made incredible progress in setting
up the pipeline. However, at this time,
some hospitals can send a summary
within 48 hours, while some can’t send
any summary yet.”
The lack of compensation is another
barrier to coordinated care. Dr.
Weinstein notes, “I do a lot of home
monitoring now, but it’s not reimbursed.
The ACO gives us hope that we’ll be
incentivized in the long run. All of us
want to see basic issues tackled but we
don’t have a reimbursement system to
do that.”
Dr. Weinstein explains, “The question
is, ‘What is the critical data coming out
of an outpatient encounter?’ It’s easy to
say that someone with congestive heart
failure should be seen often and receive
a special diet, but if that patient can’t get
up and down the steps to come to the
office, we may not be able to give them
the care they need.”

know that one of our patients was just
discharged and focus on care transitions
as points of potential intervention.”
He is focused on getting the data,
whether electronic or not, to ‘the last
mile.’ He explains, “We’re trying to
address the ‘last mile’ of connectivity –
the provider. CRISP sends the data to us
and we get it to each doctor, whether it
has to be via fax or whatever other
process the doctor can use. Each practice
has its own IT system, so we have to be
flexible. Starting this summer, we’re
putting the technology pieces in place.
You need an extra staff person to handle
the data.”
He adds, “Practices are figuring out
what their relationship is to aggregate
data. But we’re getting a better sense of
what it means to be an ACO, and we’re

Behm acknowledges, “In some cases,
we’re using 21st-century technology but
20th-century processes. It’s easy to get
frustrated, but in two years we’ve seen
great progress. We’re no longer talking
to doctors about what Meaningful Use
is, but about how they get there. We
need to take the risk to lean forward.”

We just received our final funding, and
contracts started July 1, 2013. In August
we’re training staff, then they’ll hit the
street around September, and about the
same time we’ll be rolling out a statewide advertising multi-media campaign.
We’re also receiving requests to speak at
hospitals and medical societies.

Q:

How has your experience on the
insurance side been helpful? Having

knowledge of insurance programs has
been hugely helpful in my current role.
I understand how people purchase
insurance and what’s important to them.
At Kaiser Permanente, I spent lots of
time negotiating and facilitating the
communication between employers,
insurers and doctors, and getting all of
the stakeholders to agree upon what

How has being a woman
affected your career? I discovered early

on that you have to make decisions
based on facts, not feelings. I realized
that people make decisions in business
based on data. I’m often the only
woman in the room, and I’m leading
meetings with male CEOs, many of
whom head multi-million-dollar
companies. There have been weeks on
end when I haven’t been home in time
to put my daughter to bed. I couldn’t
do this job without having an
understanding husband and family.

Q:

Will you be able to relax a bit
once enrollment begins? I tell people

that we’re racing to the start, not the
finish. Open enrollment runs for six
months. After October 1, we need to be
focused on how to make what we put in
place for the start better, and make sure
we have as many Marylanders enrolled
by March 31 as possible.
Visit www.MarylandHealthConnection.
gov to learn more, or visit Facebook:
www.facebook.com/MarylandConnect;
Twitter: @MarylandConnect and
YouTube, www.youtube.
com/marylandconnect

S THE WEATHER BEGINS
to cool and the fall foliage begins to
paint communities across Maryland in
shades of orange, red and brown, the
town of Rock Hall braces with
excitement for its biggest event of the
year. Thousands of tourists flock to the
small waterfront community in Kent
County to take part in “FallFest,”
recognized as one of the best
celebrations of music, dancing and
oyster shucking that can be found along
the East Coast. Held at The Mainstay, a
historical building in town that has
served as the venue for hundreds of
concerts and musical performances of all
genres since its opening in 1997, the
16th annual FallFest will feature a full
lineup of family-style entertainment and
fun on Saturday, October 12, 2013.
“FallFest originally started as another
way to draw people into town for a fun

By Tracy M. Fitzgerald • Photography by Jacquie Cohen Roth

FallFest, held annually in Rock Hall, is recognized as one of the best celebrations of music, dancing,
and oyster chucking found along the East Coast.

to northern ports in Pennsylvania and
New York, and southern ports along the
Virginia coast. Production and
distribution of commercial seafood was
a town priority in the early days, with
more than 80 percent of Rock Hall’s
residents making a living that revolved
around the “fruits” of the Chesapeake

Sometimes you can look out on the Chesapeake
Bay and you will see hundreds of boats
anchored. It’s this kind of scenery that people
come to Rock Hall for.”—Ron Fithian, Rock Hall town manager
weekend,” said Ron Fithian, who serves
as town manager for Rock Hall. “The
weekend centers around music, crafts and
family-friendly activities, and last year we
brought in the oyster theme, which went
over very well; in fact, we shucked over
13 bushels of oysters! Every year, the
event gets bigger and better.”
Rock Hall has long been recognized as
a seafood town that offers easy access to
the wide open spaces of the Chesapeake
Bay. Originally called Rock Hall
Crossroads, the town was positioned as
a connection point for shipments of
tobacco, seafood and other agricultural
products transported along the Eastern
Seaboard, from Baltimore and Annapolis
30 | WWW.MDPHYSICIANMAG.COM

Bay. Today, the town is best known as a
scenic sailing community, offering a
peaceful place to kick back and relax.
“We actually have more boat slips
within the town limits than we do
full-time residents,” said Fithian.
“Sometimes you can look out on the
Chesapeake Bay and you will see
hundreds of boats anchored. It’s this
kind of scenery that people come to
Rock Hall for.”
Visitors of Rock Hall have found that
getting out on the water for the day is
actually quite easy. Novices, experienced
sailors, and even those wishing to
charter a boat for a day of fishing or
relaxing on the water will find a wealth

of options, as Rock Hall has six fullservice marinas, plus a handful of
smaller ones, in operation. And for
couples or crowds who prefer to unwind
on the water over dinner and a glass of
wine, a number of special sunset sailing
packages are available.
On the entertainment front, Rock Hall
strives to please locals and tourists alike
throughout the year. In addition to
FallFest, the town puts on a series of
annual events and festivals, including a
“Pirates and Wenches Tour” that draws
thousands of people for a few days of reenactments and summertime fun every
August. There are also three museums
open year-round that spotlight and
celebrate the history of Rock Hall and its
people, and its notable contributions to
the seafood and sailing industries.
Additionally, Bayside Landing Park,
positioned alongside the Rock Hall
Harbor, offers a public swimming pool
and dual public access boat ramps, while
Ferry Park – noted as one of the best
local beach picnic sites – features a
shaded pavilion and breathtaking views
of the Chesapeake Bay.
“People that visit Rock Hall go home
and tell others about the waterfront
beauty that can be found here, that is
like no other,” said Fithian.

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SEPTEMBER/OCTOBER 2013

| 31

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HYSICIANS ARE OFTEN IN HIGHER
tax brackets, making the tax implications
of their investments especially important.
If your portfolio isn’t tailored for tax
efficiency, you could be costing yourself
tens of thousands of dollars.
A recent study charted U.S. investment
performance from 1926 to 2011.1 It
found the average annual rate of return
on the stock market dropped from 9.8
percent to 7.7 percent after accounting
for taxes. If you invested $100,000 at
9.8 percent, after 20 years your
investment would be worth $700,000 –
that’s $235,000 more than the same
investment at 7.7 percent.
A tax-efficient financial plan takes
advantage of specific strategies designed
to mitigate the effect of taxes on your
investments. Here are four ways taxsmart investing may help you keep more
of what you earn.
Tax-Managed Mutual Funds. Although
mutual funds are generally not known
for their tax efficiency, tax-managed
mutual funds seek to limit turnover and
distributions and use other strategies to
minimize tax implications.
Separate Accounts. Through separate
accounts – that is, managed investments
that buy individual securities with

pooled money – a manager can avoid
pre-existing gains/losses and short-term
capital gains, strategically harvest losses
to offset gains and identify lots for sale.
Tax-Deferred Accounts. The table below
summarizes considerations of taxable
and tax-deferred accounts in seeking to
improve your portfolio’s tax-efficiency:
Knowing When and How to Sell

Holding investments for more than one
year can help you take advantage of the
lower long-term capital gains tax rate
when you sell, though there may be
investment risks to consider.
Buying the same security at different
times and prices (“lots”) gives you
control over any gains/losses you realize.
Capital losses can be used to offset
gains dollar-for-dollar plus up to $3,000
of ordinary income each year, though
realized losses in tax-deferred accounts
cannot offset gains in taxable accounts.
Losses from wash sales (i.e., when you
sell a security at a loss but repurchase
the same or similar security within 30
days before or after the sale) cannot
offset gains or income in the current tax
year – the loss may be deferred until the
replacement property is sold or
permanently disallowed.
One other strategy worth discussing

with your financial advisor is converting
401(k) funds into Roth retirement
accounts. Although income contributed
to a Roth 401(k) is taxable the year it is
earned, it will grow and, in many cases,
be distributed tax-free.
Because of market fluctuations, your
portfolio’s performance may vary.
However, tax-smart strategies may help
you gain greater control over the taxes
you pay and keep more of what you earn.
Investors should consider the
investment objectives, risk, charges and
expenses of mutual funds carefully
before investing. This and other
information is found in the prospectus
or summary prospectus. Please read the
prospectus or summary prospectus
carefully before investing.
There are many differences between
separately managed accounts and mutual
funds, all of which should be considered
very carefully before investing.
All investments carry some level of
risk and may not be suitable for all
investors. Fixed income securities’ value
generally declines in a rising-interest-rate
environment. High-yield securities may
be subject to market, interest rate or
credit risk. Dividends are not guaranteed
and are subject to change or elimination.
Past performance is not a guarantee of
future results.
Article provided by Robert W. Baird &
Co. for Keith Levitt, Senior Investment
Consultant and Vice President at the
Baltimore office of Robert W. Baird &
Co., member SIPC. He can be reached at
klevitt@rwbaird.com. Robert W. Baird
& Co. does not provide tax advice.

Certified Financial Planner Board of Standards Inc. owns the certification marks CFP®, CERTIFIED FINANCIAL PLANNER™ and CFP® in the U.S.

SEPTEMBER/OCTOBER 2013

| 33

Good Deeds

NAMI: Educating, Supporting and Advocating
For Local Patients with Mental Health Needs

issues
they actually have, like
an injury, infection, ache
or pain.”
NAMI Maryland has
formed six education and
support-based programs,
making tools and
resources available for
patients, as well as
Shown at a recent community event (left to right) is Don Slater,
NAMI board president, Brian Hepburn, M.D., executive director of
caregivers, relatives and
Maryland’s Mental Hygiene Administration, and Kate Farinholt,
survivors. Many group
executive director of NAMI Maryland.
discussions are led and
complex cases to a specialist for care,”
facilitated by people who once faced
Farinholt added.
psychological issues themselves, and can
According to a report published by
speak from personal experience.
the U.S. Department of Health and
“We partner with the very people
Human Services, one in four adults
who originally came to us for help,”
experience a mental health disorder in
explained Farinholt. “We also work to
any given year. That same report
bring physicians and other specialists
confirms that fewer than one-third of
together to talk about the issues they
those individuals receive care for their
are seeing with patients, and how they
diagnosable condition; a statistic that
We are working hard to build relationships and directly motivates the work of NAMI
Maryland and its sister organizations,
make new connections, so that doctors can
located in each state of the country as
adequately address basic mental health issues
well as Washington, D.C.
in a primary care setting, and will know when
“NAMI was created 30 years ago as
an
advocacy organization, and it was
and how to refer more complex cases to a
clear pretty quickly that there were
specialist for care. –Kate Farinholt, executive director, NAMI Maryland
opportunities to fill the gaps and create
systems to support patients and families
can work together to address them.”
services available for patients with
who struggle with mental health issues,”
Increasing access to mental health
mental illness, with a vision to ensure
said Farinholt.
practitioners for Marylanders is a key
that those diagnosed receive the
NAMI Maryland has developed a
priority for NAMI Maryland. According
treatment and support needed to lead
brochure outlining available services and
to Farinholt, many patients often turn to
full and productive lives.
support programs. Physicians are
their primary care physician as a first
“Research shows that people with
encouraged to contact the organization
step, rather than a specialist, which can
severe and chronic mental illness die
at 410-884-8691 to request an electronic
lead to undiagnosed, untreated or under25 years earlier than the average
copy of the brochure. For further
treated conditions.
American,” said Kate Farinholt,
information, visit www.namimd.org.
“We are working hard to build
executive director of NAMI Maryland.
relationships and make new connections,
“These are the people who always
Maryland Physician would like to
so that primary care doctors can
answer ‘I am fine’ when their doctor
hear about your “Good Deeds.”
adequately address basic mental health
asks how they are doing, because they
Please share your ideas with us at
issues in a primary care setting, and will
are only focused on getting through
news@mdphysicianmag.com.
know when and how to refer more
the day. They don’t even think about the
VERYONE KNOWS THAT
mental health issues exist within the
patient population, but very few truly
understand the prevalence of these
medical challenges in communities
across Maryland. The fact is that more
than 300,000 citizens of the state have
been diagnosed with schizophrenia,
depression, bipolar disorder or another
serious mental illness. And that number
continues to grow.
Many of the patients who suffer from
these conditions face a long line of
physical, psychological and emotional
challenges that can impact their day-today functionality and capabilities.
Thankfully there is an organization
committed to providing education,
support, outreach and advocacy on their
behalf: The National Alliance on Mental
Illness (NAMI). The local affiliate,
NAMI Maryland, makes a number of